Maternal Disease

Maternal Disease

• placenta exchanges gas, nutrients, and waste products btwn maternal + fetal circulations by diffusion, active transportation, and pinocytosis (extracellular fluid absorption)

• substances w/ larger molecules are unable to cross the placenta

  • unable to enter fetal circulation d/t the “placental barrier”

  • this barrier prevents the mixing of the maternal and fetal circulations

    • some substances can cross

      • ex: infectious agents, drugs, + antibodies

What are the effects of maternal disease on the pregnancy?

• some mat diseases may directly injure the placenta and indirectly harm the fetus

• maternal vascular disease (HTN) decreases uteroplacental blood flow + compromises the placenta’s function of providing nutrients for the fetus

• FGR can be found

Maternal drug use can lead to:

• fetal addiction

• tetrogenesis

  • depends on drug, dosage, + time of exposure

  • if early in gestation → HEART

• altered uteroplacental flow

  • FGR

Amphetamines:

• stimulant drugs may be used to treat ADD/ADHD

• increased risk of fetal:

  • cleft palate

  • FGR

Barbiturates:

• cause CNS depression and may be used for sleep, anxiety, + seizures

• increased risk of fetal:

  • cardiac anomalies

  • cleft lip / palate

Cannabis:

• causes increased risk of fetal:

  • preterm birth

  • low birth weight / FGR

  • long-term cognitive issues w/ attention, memory, problem-solving skills, & behavior later in life

Cocaine:

• stimulant

• increased risk of fetal:

  • placental abruption

  • genitourinary malformations

  • limb reduction anomalies

  • cardiac defects

Nicotine:

• increased risk of Fetal:

  • spontaneous abortion

  • perinatal mortality

  • placenta previa

  • preterm delivery

  • FGR / low birth weight

Opioids:

• Codeine, Morphine, Oxycodone, Hydrocodone, Demerol, & Heroin

• increased risk of fetal:

  • placental abruption

  • miscarriage

  • stillbirth

  • FGR / low birth weight

  • cognitive delay

Fetal Alcohol Spectrum Disorder AKA:

Fetal Alcohol Syndrome

Fetal Alcohol Spectrum Disorder

• consumption of alcohol during pregnancy

• approx 45-50 g of ethanol per day suffer from the effects

• there is no threshold

  • 11% of pregnant women are problem drinkers

• permanent effects

• most common form of cognitive delay in the US today

Fetal Alcohol Syndrome is associated with:

• microcephaly

• abnormal faces

• mental delays

• CNS malformations

• behavioral problems

Maternal disease during pregnancy:

• feta infection from maternal disease can occur at various times during gestation

  • can have a wide variety of clinical outcomes

• maternal infection even before conception may have an adverse effect on future pregnancies

Maternal TORCH titers may be drawn to confirm the most common viral infections:

• Toxmoplasmosis

• Other viruses (syphilis, varicella-zoster, parovirus B19)

• Rubella (German Measles)

• Cytomegalovirus (CMV)

• Herpes

Extent of fetal damage depends upon:

• virulence of agent

• route of transmission

• gestational age

Infection that occurs before implantation:

• may result from local infection of the maternal reproductive tract

• infection may destroy the zygote or embryo

Infection that occurs after implantation:

• during organogenesis

  • accounts for the largest number of adverse fetal effects

• may lead to serious fetal abnormalities

• infectious agent enters mother, then infects placenta, enter fetal circulation and spread throughout ‘fetus’ body

Cytomegalovirus (CMV)

• most common known cause of congenital infections in humans

• features of CMV disease in neonates include:

  • hepatosplenomegaly

  • jaundice

  • thrombocytopenia

  • choriotinitis

  • cerebral calcifications

  • hydrops

  • premature foramen ovale closure

  • FGR

  • oligohydramnios

  • microcephaly

Ebstein-Barr Virus (EBV)

• causes mononucleosis

• uncommon in pregnant women

• has been linked to spontaneous abortions, stillbirths, low-birth-weight infants, congenital heart anomalies, and microphthalmia

Herpes Simplex

• Infection during first half of pregnancy has been associated w/ spontaneous AB & stillbirths

  • associated congenital malformations

    • microcephaly, hydrancephaly, intracranial calcifications, microphthalmia, hepatosplenomegaly

    • C-section indicated if present in birth canal

Varicella-Roster (Chicken Pox)

• congenital abnormalities

• Postnatal newborn disease (benign to fatal)

• Zoster (shingles)

  • May appear months or years after birth

• FGR, limb aplasia, microphthalmia, brain calcifications

  • Observed when virus transmitted 8-20 weeks GA

Rubella (German Measles)

• contagious viral infection usually causing mild symptoms like fever, swollen glands, and a pinkish-red face

• MMR vaccine protects against virus

• Infection during pregnancy may result in spontaneous AB, stillbirth, or congenital defects

  • Microcephaly, hydrocephaly, cephalocele, cardiac anomalies, eye defects, FGR, deafness, and cognitive delay

HIV

most cases in children are a consequence of transmission of infection from mother to infant near the time of birth

Factors affecting HIV transmission from mother to infant include:

• maternal HIV particles

• Effectiveness of maternal and fetal immune response

• Effectiveness of maternal and fetal immune response

• Integrity of the placental barrier

• Maternal viral load**

• Hx of anti-viral meds

Syphilis

• Syphilis infection early in pregnancy may result in spontaneous AB

  • Infection later in pregnancy:

    • stillborn / neonatal death

  • Infection very late in pregnancy:

    • signs of congenital syphilis may not appear for 2-4 weeks

      • hepatosplenomegaly, hyperbilirubinemia, hemolysis, lymphadenopathy

Gonorrhea

• increased incidence of prematurity, prolonged fetal membrane rupture, chorioamnionitis, sepsis, FGR

  • can be treated w/ Penicillin

Parasitic Infections:

• Toxoplasmosis

• Malaria

• Both treated w/ antiparasitic drugs**

Toxoplasmosis

• usually acquired in last semester

• FGR, hydrocephaly, microcephaly, cerebral calcifications*, hepatosplanomegaly, fetal demise

Malaria is associated w/:

• placental insufficiency

• FGR

• low birth weight

• abortion

• stillbirth

What is the most common maternal disorder?

Diabetes mellitus

Maternal Diabetes types:

• Type I

  • Insulin Dependent

• Type II

  • Non-Insulin Dependent

• Other/Secondary Diabetes

  • Pancreatic disease or pancreatectomy, hormones, drugs, or chemical + certain genetic syndromes

• Gestational Diabetes*

  • Diabetes mellitus only during pregnancy

Maternal Diabetes is at increased risk for:

• early + late term loss

• congenital anomalies

• growth disturbances

• c-section

• shoulder dystocia

Maternal Diabetes causes certain maternal complications:

• difficulty controlling glucose levels

• infections

• pyelonephritis

• delivery complications

Fetal anomalies related to maternal DM:

• macrosomia

• CHD (TOGV, TOF), NTD’s, caudal regression

• single umbilical artery

• concurrent maternal vascular disease increases risk for FGR

Maternal Diabetes

• disorder of carbohydrate metabolism related to insulin deficiency and characterized by hyperglycemia

• glucose is the main ““fuel” for fetal growth

  • means maternal glucose levels being too high (not enough insulin production = macrosomia

• associated w/ polyhydramnios and can cause:

  • PTL, PROM, + Maternal Discomfort

Macrosomia

• greater than the 90th %ile for GA

• >4500 grams at birth (9lb 9oz)

Maternal DM procedure:

• screen for congenital anomalies

• check placental thickness (2.5-5cm) + AFV

• fetal growth

• after 28 weeks → BPP, NST, + Umbilical Artery Dopplers are often used to monitor fetal well-being

  • twice weekly testing

Cardiac anomalies associated w/ mat DM:

• TOGV w/ or w/o VSD

• VSD

• ASD

• Coarctation of the aorta w/ or w/o VSD

• Cardiomegaly

GI anomalies associated w/ mat DM:

• duodenal atresia

• anorectal atresia

• small left colon syndrome

Renal anomalies associated w/ mat DM:

• hydronephrosis

• renal agenesis

• ureteral duplication

CNS anomalies associated w/ mat DM:

• caudal regression syndrome

• NTD’s

• anencephaly

• microcephaly

Other anomalies associated w/ mat DM:

single umbilical artery

Gestational Diabetes manifestation:

• manifest signs of dm during pregnancy and have normal glucose levels when not pregnant

• detected primarily btwn 24-28 weeks GA

• gestational diabetes occurs when an expectant woman’s pancreas doesn’t produce enough insulin to account for placental hormone fluctuations

• GDM may be diet controlled or require insulin

Gestational Diabetes risk factors:

• previous stillbirth

• baby w/ congenital anomalies

• prev macrosomic infant

• family hx of DM

Possible effects of GDM on baby after birth:

• increased risk of breathing difficulties

• low blood sugar levels

• jaundice

2 Types of HTN:

• Pregnancy Induced Hypertension

  • pre-eclampsia, severe pre-eclamsia, eclampsia

• Chronic Hypertension

  • present prior to pregnancy

Pre-eclampsia

HTN w/ proteinuria + edema

Severe Pre-eclampsia

Immediate delivery needed

Eclampsia

Risk for seizures and coma

HELLP Syndrome

• H

• EL

• LP

• associated w/ pre-eclampsia

• early diagnosis is critical b/c of the morbidity and mortality rates associated w/ the syndrome are reported to be as high as 25%

HELLP Syndrome risk factors:

• rarely occurs until the third trimester

• 1/3 of cases develop within 2 days after delivery

• more likely to occur in women of African descent and multiparous Caucasian women

• Increased risk in women w/:

  • Family hx if HELLP

  • pre-eclampsia

HELLP syndrome symptoms:

• headache

• Nausea / vomiting / indigestion w/ pan after eating

• Epigastric (abd) or wubsternal (chest) tenderness

• RUQ pain (from liver distension)

• Shoulder pain / pain when breathing deeply

• Bleeding

• Swelling

• High BP

• Proteinuria

Sickle cell Disease (Anemia)

• inherited disorder that affects the hemoglobin molecule in the blood

• inflexible sickle-shaped cells cause complications d/t inability to change shape in the small blood vessels of the body

Sickle Cell Anemia is more common in individuals from:

• Africa, central / South America, the Caribbean islands, Mediterranean countries, India, and Saudi Arabia

• African-Americans have 1/500 chance in inheriting this (very high)

• Hispanic Americans have a 1/1000-1400 chance

Sickle Cell Disease is at risk for fetal:

• spontaneous AB

• prematurity

• stillbirth

• short femurs

• LBW / FGR

Monitor Sickle Cell Disease pt’s for:

• FGR

• Abnormal Umbilical Artery Doppler

Sickle Cell Anemia treatment:

• women w/ sickle cell disease may be urged to take iron and folic acid supplements during pregnancy

• may require blood transfusions

Thalassemia (Beta-thalassemia)

• reduction in hemoglobin and RBC production that leads to anemia

  • D/t gene mutation and similar to Sickle Cell Disease

What is one of the most common maternal autosomal recessive genetic abnormalities associated w/ pregnancy worldwide?

Beta-thalassemia

Two forms of Beta-Thalassemia:

• Cooley anemia / thalassemia major → more severe

• Thalassemia intermidia

There is an increased risk of thalassemia in individuals from:

• Mediterranean countries

• North Africa

• The Middle East

• India

• Central Asia

• Southeast Asia

Thalassemia is associated with:

• most women w/ thalassemia major die before reproductive age

• Can be associated w/ fetal hydrops

Thrombophilias

• group of disorders that promote blood clotting

  • Most common antiphospholipid syndrome (APS)

Thrombophilias are at increased risk of:

• repeated late first-trimester miscarriages

• Stillbirth

• Placental abruption

• FGR

• Maternal deep vein thrombosis

Rh Sensitization

• occurs when Rh- woman is pregnant with an Rh+ fetus

• Cells from Rh+ fetus enters mom’s bloodstream

• Mom becomes sensitized and as a result antibodies form to fight Rh+ cells

• In the next Rh+ pregnancy the fetal cells are attacked due to the antibodies formed

What does Rh Sensitization result in?

• destruction of the fetal RBC’s lead to fetal anemia

• Immune Hydrops

• Rh- Moms are treated w/ injection called RhoGAM to prevent fetal cell attack

Systemic Lupus Erethmatosus

• common in women of childbearing age

• Spontaneous AB / Fetal death is common

• Placenta affected by immune complex deposits / inflammatory response in placental vessels can account for:

  • ↑ loss

  • spontaneous AB’s

  • IUGR

• Risk for congenital Heart Blocks + Peric Effusion

Urinary Tract Disease

• 4-6% of pregnant women w/ asymptomatic bacteriuria leads to pyelonephritis if untreated

• Pyelo Symptoms: fever, flank pain, WBC’s in urine

• Hydronephrosis symptoms:

  • flank pain

  • prescence of progesterone dilatory effect on ureter muscle

  • ↑ uterize size d/t ureter compression at pelvic brim

Hyperemesis Gravidarum

• dehydration electrolyte imbalance

• hospitalization for IV fluids

• confirm lack of maternal gallstones, ulcers, trophoblastic disease

Maternal Obesity

• BMI >30

• 3 major antenatal complications are:

  • ↑ risk NTD’s → d/t poor diet

  • ↑ risk for multiples

  • ↑ risk of UTI’s

Fetal Demise

• absence of a FHR confirmed by Color Dp, PW DP, M-mode and/or Power Dp

• May present as S<D, decreased fetal movement, post-trauma, or asymptomatic

• always document absence of FHR + always do biometry

  • to estimate how long ago demise occured

Fetal Demise U/S appearance:

• may see skin, scalp, + generalized edema

• spalding sign** (cranial bone overlapping)

• ascites

• oligohydramnios

• abnormal position / spine curvature

Potential fetal demise causes

• spontaneous

• infection

• chromosome abnormality

• congenital anomaly

• preeclampsia

• placental abruption

• diabetes

• FGR

• Rh incompatibility